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Male infertile, role of imaging the diagnosis andmanagementAbstractSection:

The role of imaging is to identify a potentially correctable cause of infertility.

Imaging facilitates selection of the best method for impregnating the female partner, suchas sperm aspiration from the epididymis or seminiferous tubules followed by invitro fertilization or intracytoplasmic sperm injection.

Transrectal and scrotal ultrasound are the imaging modalities of choice in the radiologicalassessment of male infertility.

MRI of the prostate and stimulated colour Doppler of the penis can have a role in particular cases.

Infertility is a common problem, with male infertility detectable in approximately 50% of involuntarily childless couples.

Transrectal and scrotal ultrasound are the ima in techni!ues of choice, allowin detailed examination of the malereproductive system. "o cause for subfertility is detected #idiopathic infertility$ in the ma ority of patients. &hen acause is detected, a'oospermia is often seen and may be non(obstructive or obstructive. )aricoceles are associatedwith infertility but the si nificance of this relationship is uncertain* sur ical or radiolo ical repair of varicoceles is notreco ni'ed as appropriate treatment for infertility. +ltrasound is more sensitive than clinical examination in thedetection of varicoceles. unctional or vaso enic erectile dysfunction can impair conception in couples. +ltrasoundwith intracavernosal prosta landin administration allows assessment of the causation of erectile dysfunction and maydistin uish between arterial and venous problems. -etection of the cause of infertility is important to allow plannin of the most appropriate techni!ues for achievin conception.

Section:

Infertility is defined as the failure to conceive after re ular unprotected sexual intercourse in the absence of /nownreproductive patholo y , over a period of 1 or 2 years 3 14. pproximately one in four couples does not achievepre nancy within 1 year of tryin * of these, 15% will see/ medical treatment. In the +nited States, infertility affectsover six million couples. In many infertile couples, both male and female factors coincide, resultin in subfertility. 6alecauses of infertility are found in up to 50% of involuntarily childless couples 3 2, 74.

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In about 70% of infertile male patients, a physical cause for infertility is found* these causes include con enital orac!uired uro enital abnormalities, enetic and immunolo ical factors, endocrine disturbances, enital tract infectionsand erectile dysfunction. In the remainder, no cause is found and the patients are labelled as havin idiopathic maleinfertility. 9atients classified as havin idiopathic male infertility have a normal physical examination and endocrinelaboratory testin , and often have no /nowled e or prior history of fertility problems. Semen analysis shows areduction in the sperm count #oli o'oospermia$, decreased motility #astheno'oospermia$ or morpholo ical

abnormalities #terato'oospermia$. bnormalities in sperm function and number often coexist* therefore, the umbrellaterm oli o(astheno(terato'oospermia syndrome is used.

'oospermia is defined as the absence of both spermato'oa and spermato enic cells in semen and post(e aculateurine. 'oospermia can usefully be subdivided accordin to non(obstructive or obstructive causes. bstruction is aless fre!uent cause of a'oospermia, occurrin in 15;20% of men with a'oospermia 3

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)enous draina e at the testicular level is via the pampiniform plexus of veins above and behind the testis, which forma sin le vein in the re ion of the in uinal rin . The testicular vein ascends to the inferior vena cava on the ri ht andthe renal vein on the left 3 A4.

Imaging techniques in infertilitySection:

Coth partners are routinely assessed in the evaluation of infertility* if the male partner is subfertile #on the basis ofsemen analysis$, a urolo y referral is indicated. +pon referral, a detailed clinical history, examination and laboratorytestin will be performed. The superficial nature of the scrotal sac and the prostate #transrectal approach$ allow forassessment of the male reproductive tract by ultrasound ima in . The combination of transrectal ultrasound #TD+S$and scrotal ultrasound allows ade!uate morpholo ical assessment of the essential parts of the male reproductivesystem. Scrotal ultrasound can be used to measure testicular volume, to assess testicular texture, to detectvaricoceles and to exclude testicular patholo y. TD+S can be used to detect any causes of mechanical obstructioninvolvin the seminal vesicles, e aculatory ducts or vas deferens. @istorically, vaso raphy has been the old(standardtechni!ue for evaluatin the reproductive tract, but its invasive nature and associated ris/s mean that it is now rarely

used. In selected cases, 6DI can clarify TD+S findin s.

The role of ima in is to identify a potentially correctable cause of infertility, allowin the detection of disorders thatobstruct sperm transport and con enital anomalies. It also uides selection of the best method for impre natin thefemale partner, such as sperm aspiration from the epididymis or seminiferous tubules followed by in vitro fertili'ationor intracytoplasmic sperm in ection. 9enile ima in is valuable for assessin causes of erectile dysfunction that mayresult in failure to conceive. In addition to these standard tests, ima in of the urethra usin ultrasound orfluoroscopic techni!ues and, if appropriate, an io raphic assessment of the testicular veins may bere!uired.Ima in and associated investi ations should be performed with understandin of the sensitive nature ofinfertility and should be performed in a warm private settin with a chaperone present.

Ultrasound techniquesScrotal ultrasound

The examination is performed with a hi h(fre!uency #A;12 6@'$ linear(array transducer probe. The probe len thshould allow accurate lon itudinal measurements of the testis. The patient is examined in a supine, recumbentposition. The scrotal sac can be stabili'ed by as/in the patient to cross his le s and placin a paper towel betweenthe thi hs. The testes should be examined in two planes #transverse and lon itudinal$ because comparative viewsofthe testes allow assessment of echotexture. 8olour flow -oppler evaluation and volume measurements should beperformed routinely. )olume measurement is usually calculated as: len th E hei ht E width E 0.51. total volume#both testes summated$ of F70 ml is considered normal 3 G4.

Transrectal ultrasound

The patient is positioned in a left lateral decubitus position. hi h(fre!uency endorectal probe should be used with a

condom probe cover. -i ital examination of the rectum may be performed prior to the procedure to assess the rectalcavity and to chec/ that no endorectal lesions are present. The probe is inserted carefully with ade!uate lubrication.Systematic evaluation of the terminal vas deferens, seminal vesicles, e aculatory ducts and prostate is carried out inaxial and sa ittal planes.

B-mode and dynamic colour Doppler ultrasound of the penis

hi h(fre!uency linear(array probe with a small footprint should be used. The penis is held in the anatomical positionby the patient and baseline C(mode ultrasound ima in is performed in lon itudinal and transverse planes. @i h(

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trophy may occur followin previous inflammation, liver cirrhosis, oestro en treatment, hypo(pituitary disease anda ein . trophy is associated with a reduction in spermato enesis. n ultrasound, there is a lobal reduction in thevolume of the testis # i ure 7$. decrease in both the testicular reflectivity and vascularity are common findin s. Theepididymis usually appears normal 3G4.

!rchitis and epididymo"orchitis

=pididymitis and epididymo(orchitis are common causes of acute scrotal pain* if chronic, they may causespermato enic arrest and result in testicular atrophy # i ure

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the enital duct, and can identify chan es that result from distal duct obstruction. In patients with , scrotalultrasound is often abnormal. In one study of men with proven , G?% of the ultrasound examinations wereabnormal. bnormalities associated with obstruction included tubular ectasia of the epididymal head, taperin ofthe epididymal tail, absence of the epididymis and the presence of hetero eneous masses alon the epididymalcourse 3 1G4. In the same study, the median testicular volume in was si nificantly hi her #median 11.? ml$ than in" #median G.7 ml$.

The causes of obstructive a'oospermia are detailed in Table 2. In practice, TD+S is the modality of choice forassessin the cause of . In a study of 2A? men with a'oospermia and low e aculate volume, 25% had a normalTD+S, 7

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the e aculatory ducts, resultin in obstruction. The appearances of 6ullerian and utricular cysts on TD+S, when noextraprostatic component is present, are indistin uishable. 6DI can be useful in confirmin the dia nosis, allowinclear delineation of the ori in of the abnormality. 6DI may also allow differentiation from posterior bladderdiverteculaeand vas deferens cysts, which can have a similar appearance on TD+S. n 6DI, the presence of blood andproteinaceous fluid within a 6ullerian cyst can result in hi h T 1 wei hted si nal 325 4. +ro enital sinus or e aculatoryduct cysts are midline prostatic cysts that derive from the &olffian duct and uro enital sinus, into which the

e aculatory ducts empty. They can become very lar e and extend beyond the prostate 32? 4. 9aramedian or lateralintraprostatic cysts are &olffian in ori in and are rarely seen in clinical practice. Kar e cysts can be aspiratedtransrectally under ultrasound uidance but the results are often short(lived 3 2? 4.

Erectile dysfunctionSection:

-ynamic assessment of the arterial supply to and venous draina e of the penis can be performed usin stimulatedcolour -oppler ultrasound # i ure J$. "ormal arterial flow shows a pea/ systolic velocity of 75 cm s L1 or reater andindicates arterial sufficiency. )elocities of 25;7< cm s L1 are e!uivocal. In the roup with velocities of 25;7< cm s L1,

A5% showed evidence of arterial disease when assessed with arterio raphy 32

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measured at 20 min followin the in ection of 9H= 1remains elevated at 1A.5 cm s L1, indicatin that a venous lea/ is aproblem.

Table 1. The aetiology and fre uency of factors causing maleinfertility

Table &' The aetiolo y and fre!uency of factors causin male infertility

Table 2. The classification and causes of obstructive azoospermia

Table (' The classification and causes of obstructive a'oospermia

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!. "orld #ealth $rganization. "#$ manual for standardised investigation and diagnosis ofthe infertile couple %!st edition&. 'ambridge, ()* 'ambridge (niversity +ress, ---.

. rugh /M, 0ipshultz 0I. Male factor infertility. 1valuation and management. Med Clin North Am --2344*567849. 'rossRef

5. alen :#, Rutherford :;. Management of infertility. BMJ --73559*6-48!!. 'rossRef 2. 1ngin , Rozanes I. Transrectal (> and endorectal

MR imaging in partial and complete obstruction of the seminal duct system. : comparative

study. Acta Radiol ---32!* 448?9. 'rossRef ,Medline9. enet :1, Melman :. The epidemiology of erectile dysfunction. Urol Clin North

Am !??93 *6??87-?.6. "il=ins ';, >riprasad >, >idhu +>. 'olour Doppler ultrasound of the penis. Clin

Radiol --5394*9!28 5. 'rossRef , Medline7. >adler T", 0angman ;, 0eland ;. 0angman@s medical embryology. altimore* 0ippincott,

"illiams A "il=ins, --6* 5?826.4. >idhu +>. Diseases of the testis and epididymis. In* aBter idhu +>, editors.

(ltrasound of the urogenital system. >tuttgart* Thieme, --6*!9584-.?. eddy +,

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. Radiol --736 * 4?85- . 'rossRef ,Medline!2.

Cicarra /, 'erruto M, 0iguori , Citzpatric= DR, #argreave T . The incidence of cystic fibrosis genemutations with congenital bilateral absence of the vas deferens in >cotland. Br J

Urol !??737?*7287. 'rossRef , Medline2.

'ornud C, :mar 1, #amida ), Thiounn , #elenon $, Moreau ;C. Imaging in malehypofertility and impotence. Br J Urol ---346*!95865. 'rossRef

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+arsons R , Cisher :M, arE'hama , Mitty #:. MR imaging in maleinfertility. Radiographics !??73!7*6 7857. 'rossRef , Medline

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Meacham R , Townsend RR, Drose ;:. 1jaculatory duct obstruction* diagnosis andtreatment with transrectal sonography. AJR Am J Roentgenol !??93!69*!2658 6. 'rossRef , Medline

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enson ' , :runy ;1, /ic=ers M:. 'orrelation of dupleB sonography with arteriography in patients with erectile dysfunction. AJR Am J Roentgenol !??53!6-*7!85. 'rossRef , Medline

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riprasad >, "il=ins ';, Donaldson , Muir idhu +>. +hentolamine reEdosing during penile dynamic colour Doppler ultrasound* a practical method to abolish afalse diagnosis of venous lea=age in patients with erectile dysfunction. Br J

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